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.^mith,  Fre-dcYieK    Charley 


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UNITED  STATES  PUBLIC  HEALTH  SERVICE 

TUBERCULOSIS 

ITS   PREDISPOSING   CAUSES 


BY 


F.  C.  SMITH 

Passed  Assistant  Surgeon 
United  States  Public  Health  Service 


SUPPLEMENT  No.  3 

TO  THE 

PUBLIC  HEALTH  REPORTS 

February  7,  1913 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 

1913 


c< 


TUBERCULOSIS. 

ITS  PREDISPOSING  CAUSES. 

By  F.  C.  Smith,  Passed  Assistant  Surgeon,  United  States  Public  Health   Service. 

The  public  is  already  fairly  well  instructed  concerning  the  exciting 
cause  of  tuberculosis,  i.  e.,  the  tubercle  bacillus.  It  is  common 
knowledge  that  sputum  containing  this  germ  is  the  chief  means  of 
spreading  infection.  Spray  from*  a  coughing  consumptive,  dust, 
flies,  doorknobs,  drinking  cups,  and  towels  are  common  means  of 
spreading  infection.  There  are  constantly  over  1,000,000  people  in 
the  United  States  sick  with  tuberculosis,  many  of  whom  are  careless 
or  ignorant.  There  are  also  other  sources  of  infection.  As  a  result 
the  tubercle  bacillus  is  everywhere,  and  in  spite  of  all  precautions 
the  ordinary  individual  at  an  early  age  is  already  slightly  infected 
with  tubercle  bacilli. 

INFECTION    PRACTICALLY    UNIVERSAL   BY   THE    SIXTEENTH   YEAR. 

If  a  drop  of  tuberculin  is  rubbed  into  the  abraded  skin  of  a  very 
young  child  no  reaction  follows.    If  the  drop  of  tuberculin  be  rubbed 
into  the  skin  of  a  person  who  is  or  has  been  infected  with  tubercu- 
losis a  reaction  follows  in  a  few  hours,  manifested  by  a  small  area  of 
redness,  which  disappears  after  a  few  days  and  is  unattended  by  any 
harmful    effects.     This   is   the    cutaneous   tuberculin    test    of    Von 
Pirquet. 
It  was  soon  found  that  hundreds  of  people  reacted  to  the  tuberculin 
^,test  who  had  no  sign  of  tuberculosis.     About  90  per  cent  of  white 
children  between  the  ages  of  12  and  13  and  practically  all  adults 
*  will  give  positive  reactions,  but  the  children  of  different  communi- 
|  ties  give  slightly  different  results.     The  Indians  of  Taos,  N.  Mex., 
J  an  isolated  community,  were  found  during  the  recent  investigation  of 
disease  among  the  Indians  by  the  United  States  Public  Health  Serv- 
ice to  be  almost  free  from  tuberculosis,  and  only  3  of  the  64  school 
children   tested   there   showed   positive   reactions.     Of    1,145    other 
Indian  school  children  tested,  however,  779  reacted  positively.    We 
must  conclude  that  the  communitjr  free  from  almost  universal  in- 
fection is  rare.     The  examination  of  large  numbers  of  bodies  dead 

(3) 

77411°— 13 


from  other  causes  than  tuberculosis  in  various  parts  of  the  world  has 
shown,  at  the  hands  of  numerous  investigators,  that  a  small  area  of 
healed  or  latent  tuberculosis  can  almost  always  be  found  in  the  adult. 

TUBERCLE   BACILLI    HARMLESS  UNDER   CERTAIN   CONDITIONS. 

Most  of  the  children  who  react  to  the  tuberculin  test  are  not  only 
apparently  healthy  but  never  break  down  from  tuberculosis,  although 
they  have  been  the  recipients  of  a  large  or  small  dose  of  living  tubercle 
bacilli.  Practically  all  adults  are  infected  to  some  degree  with 
tubercle  bacilli  and  though  many  develop  tuberculosis,  especially 
during  their  years  of  greatest  stress,  the  majority  successfully  resist 
it.  It  will  at  once  occur  to  the  reader  that  infection  is  perhaps  a 
matter  of  dosage,  that  a  large  number  of  virulent  bacilli  inhaled  or 
ingested  may  cause  tuberculosis  in  an  individual,  whereas  a  small 
dose  will  be  rendered  innocuous  by  a  high  degree  of  resistance  from 
a  virile  body.  This  is  undoubtedly  true.  There  is  even  a  certain 
measure  of  protection  derived  from  a  small  dose  of  tubercle  bacilli 
well  resisted. 

These  latent  germs  of  infection,  the  potential  factors  of  tubercu- 
losis, in  themselves  probably  give  a  certain  degree  of  immunity 
against  the  effects  of  larger  doses  which  one  may  later  unfortunately 
experience.  The  individual  is  in  a  small  degree  vaccinated  against 
tuberculosis.  Too  much  comfort  must  not  be  derived  from  this, 
however,  as  in  young  children  infection  of  any  degree  is  apt  to  be- 
come generalized  and  rapidly  fatal,  and  large  dosage  due  to  repeated 
exposures  will  cause  even  an  adult  to  succumb.  Hence  no  sanitary 
precaution  should  be  neglected  at  any  age  to  reduce  the  frequency  and 
extent  of  exposure  to  tubercle  bacilli.  It  must  be  remembered  also 
that  these  bacilli  of  latent  infection  are  nevertheless  living  bacilli 
capable  of  remaining  virulent  in  the  living  body  for  many  years  and 
that  the  apparently  healthy  host  may  lose  his  immunity  to  them  in 
several  ways,  many  of  which  are  not  well  understood.  The  most 
common  ways  of  losing  immunity  and  the  ones  most  easily  prevented 
are  those  discussed  in  this  paper — the  predisposing  causes  of 
tuberculosis. 

WEAKENED   RESISTANCE    OR   PREDISPOSITION. 

In  very  early  times  it  was  observed  that  tuberculosis  is  more  apt 
to  occur  at  certain  ages  and  under  certain  conditions  of  life.  Hippoc- 
rates, the  father  of  medicine,  noted  that  it  was  most  frequent  between 
the  ages  of  18  and  35,  a  period  which  calls  for  the  greatest  physical 
and  mental  efforts.  Dr.  Bonney  mentions  "  the  old  English  idea  that 
consumption  was  the  cause  of  death  of  nearly  all  hard  zealots  in  the 
field  of  letters,  law,  love,  medicine,  and  religion."  It  is  common 
knowledge  now  among  physicians  that  any  cause  which  weakens  the 


individual,  lessens  his  resistance  and  predisposes  to  tuberculosis.  A 
powerful  physique  is  no  safeguard.  Bridge  says :  "  Physically  strong 
people  will  not  resist  tuberculosis  better  than  less  muscular  subjects. 
Athletes  acquire  it  rather  more  readily  than  thin,  weakly  people  with 
spare  musculature  but  normal  organic  vigor."  Baldwin  states: 
"Adults  of  good  physique,  in  functional  and  organic  health,  possess  a 
nearly  perfect  protection  against  natural  infection  by  tubercle 
bacilli,"  but  adds,  "Any  weak  moment  *  *  *  may  play  the  part 
of  a  predisposition."  To  maintain  normal  vigor  and  functional 
health  requires  the  observance  of  a  multitude  of  details  and  a  con- 
sideration of  the  chief  causes  of  lowered  vitality. 

LACK   OF  PROPER   FOOD. 

The  well  fed  resist  tuberculosis  well,  the  underfed  yield  readily. 
Clinical  observations  have  abundantly  proved  this  fact  in  both  man 
and  animals.  Actual  want  is  by  no  means  the  commonest  cause  of 
poor  nourishment  although  it  must  be  reckoned  with,  especially  in 
our  great  cities,  such  as  New  York,  where  it  is  said  many  hundred 
school  children  go  breakfastless  to  school.  In  the  average  American 
household  too  little  time  is  given  to  the  study  of  children's  diet  dur- 
ing the  first  decade  of  life  and  even  when  food  is  properly  prepared 
for  them  it  must  not  be  forgotten  that  it  often  takes  time  and  patience 
to  induce  a  playful  and  capricious  child  to  eat  the  proper  things  in 
sufficient  quantities.  Every  attack  of  indigestion,  every  missed  or 
partially  consumed  meal  has  its  adverse  effect  on  nutrition  at  any 
age  of  life.  Many  people  are  underfed  who  consider  themselves 
well  fed.  The  rich  business  man  who  hastily  consumes  a  scanty 
breakfast  of  toast  and  coffee  and  works  hard  all  day  in  an  office  with 
only  a  hasty  lunch  at  noon,  can  not  consider  himself  well  fed  even 
though  he  consumes  a  full  meal  in  the  evening  and  has  a  late  lunch 
after  the  theater.  His  child  who  refuses  at  table  wholesome  ar- 
ticles of  food,  such  as  bread  and  butter,  vegetables  and  meat,  can  not 
maintain  a  satisfactory  degree  of  nourishment.  Candy  and  cookies 
taken  between  meals,  and  frequently  accountable  for  the  lack  of  appe- 
tite at  table,  can  not  possibly  be  considered  a  satisfactory  substitute 
for  proper  food. 

A  lack  of  knowledge  of  food  values  is  very  common,  especially  in 
cities  where  delicatessen  products  made  to  tempt  the  eye  and  palate 
too  often  in  the  busy  urban  life  take  precedence  over  wholesome 
soups,  roasts,  and  stews  from  the  home  kitchen.  It  should  not  be 
forgotten  that  fatty  articles  of  food,  including  butter,  fat  meats, 
and  olive  oil  are  especially  valuable  in  building  up  resistance  to 
tuberculosis,  but  the  diet  must  be  suited  to*  the  age  of  the  individual. 
Bread  and  butter,  meat,  and  abundant  vegetables  must  not  be  slighted 
simply  because  milk  and  eggs  are  so  commonly  mentioned  in  this 
connection  as  ideal  foods. 


EXHAUSTION. 

Next  to  lack  of  food,  great  fatigue  is  the  greatest  predisposing 
factor  in  tuberculosis.  Exhaustion  may  be  produced  by  long  hours 
of  heavy  work  and  also  by  lack  of  sleep,  by  worry,  long  hours  of 
study  and  any  excessive  or  prolonged  exertion,  either  work  or  play. 
Dancing  in  itself  is  harmless,  but  if  it  comes  at  the  end  of  a  day's 
work  and  is  indulged  in  until  late  hours  its  effects  upon  general  health 
will  be  deleterious.  Even  outdoor  sports,  which  are  certainly  to  be 
encouraged,  may  defeat  their  chief  end  if  indulged  in  immoderately 
or  to  the  exclusion  of  proper  resting  periods.  Child  labor,  either  in 
factory  or  at  home,  excessively  long  working  hours,  occupations 
which  can  not  be  interrupted  for  Sunday  rest  or  which  tempt  or 
drive  to  excessive  effort  or  "  speeding  up,"  all  tend  to  weaken  resist- 
ance and  predispose  to  tuberculosis. 

BAD    AIR. 

The  air  of  poorly  ventilated  rooms  is  bad.  Not  only  in  factory  and 
workshop  and  in  overheated,  poorly  ventilated  places  of  amusement, 
but  in  his  own  home,  the  ordinary  individual  frequently  lacks  good 
air.  When  air  is  breathed  and  rebreathed  it  becomes  laden  with 
poisonous  matters.  A  person  fresh  from  the  pure  outdoor  air  will 
feel  oppressed  upon  entering  such  an  atmosphere  and  will  notice  a 
bad  odor  in  the  room.  When  he  goes  forth  he  will  carry  the  taint 
of  such  a  place  in  his  garments.  One  who  lives  long  in  vitiated  air 
grows  pale,  loses  appetite,  takes  cold  easily,  and  becomes  tired  upon 
slight  exertion.  If  several  people  occupy  the  room,  or  if  gas  or  oil 
is  burned  in  it,  the  contained  air  rapidly  becomes  highly  polluted 
unless  it  is  frequently  renewed.  The  effect  of  bad  air  and  lack  of 
sunshine  on  infected  rabbits  has  been  studied  by  Dr.  Trudeau,  who 
found  that  animals  confined  in  a  cellar  died  of  tuberculosis,  while 
similarly  infected  ones  recovered  in  the  open  air.  Remembering  that 
many  babies,  most  children,  and  all  adults  are  infected  with  tubercle 
bacilli,  and  knowing  the  fatal  effects  of  close  confinement,  the  need 
of  good  ventilation  becomes  imperative. 

Air  flows  very  much  as  water  does;  to  renew  itself  in  a  room  it 
should  have  an  inlet  and  an  outlet,  A  bucket  of  dirty  water  half 
imersed  in  a  flowing  crystal  stream  remains  dirty.  A  small  trickle 
of  clear  water  will  not  cleanse  a  pond  constantly  receiving  pollution 
from  another  source.  A  room  must  be  well  flushed  with  flowing  air 
to  sweep  out  pollution,  and  the  flow  should  be  constant  both  in 
summer  and  winter.  Ventilation  at  night  is  most  important,  the 
fear  of  night  air  being  without  any  foundation.  With  sufficient  bed- 
clothes there  can  be  no  excuse  for  leaving  even  partially  closed  a 
single  window  in  the  room. 


OTHER   DISEASES. 

It  has  long  been  known  that  measles  and  whooping  cough  in  chil- 
dren are  especially  liable  to  be  followed  by  tuberculosis  of  the  lungs, 
and  every  effort  should  be  made  to  protect  a  child  from  these  dis- 
eases. Mouth  breathing  should  be  corrected  and  adenoids  removed. 
Scarlet  fever,  influenza  and  colds,  typhoid  fever,  and  all  diseases 
which  lower  resistence,  lessen  nourishment,  and  increase  the  stress  of 
life  at  any  age  must  be  reckoned  with  as  important  factors  in  pre- 
disposing to  tuberculosis. 

ALCOHOL    AND    TOBACCO. 

There  was  a  time  when  whisky  was  considered  good  for  the  tuber- 
culous patient,  and  there  have  been  some  who  believed  in  the  anti- 
septic powers  of  smoke.  It  is  now  known  and  taught  that  neither  of 
these  agents  has  any  place  in  the  prophylaxis  or  treatment  of  this 
disease.  The  inhaled  smoke  of  cigarettes  is  especially  harmful  to  the 
delicate  air  passages  as  well  as  weakening  in  its  effects  on  the  system. 
Alcohol  in  immoderate  quantities  impairs  digestion,  encourages 
irregular  habits,  and  seems  to  especially  predispose  the  subject  to 
pulmonary  disease. 

SUMMARY. 

At  an  early  age  practically  all  people  have  become  slightly  infected 
with  living  tubercle  bacilli.  This  fact  need  not  cause  alarm,  because 
it  probably  gives  a  slight  degree  of  protection  against  subsequent 
infection.  Safety,  however,  depends  on  the  maintenance  of  a  high 
degree  of  organic  resistance  to  prevent  these  latent  bacilli  from  pro- 
ducing active  tuberculosis.  This  is  not  to  be  accomplished  by  becom- 
ing an  athlete  but  by  the  daily  observance  of  general  hygienic  princi- 
ples throughout  life.  Keep  the  body  well  nourished;  avoid  great 
fatigue;  work  and  sleep  in  well-ventilated  rooms,  in  freely  flowing 
air,  and  spend  as  much  time  as  possible  outdoors,  but  carefully  reserve 
hours  for  adequate  rest  as  well  as  for  recreation ;  practice  deep  breath- 
ing and  proper  carriage ;  avoid  other  diseases  as  far  as  possible ;  and 
be  temperate  in  all  things. 

o 


